<!doctype html>
<html>
{include file="head.html"}

<body>
<div class="header" >
    <a  class="left-btn pointer" href="{$appkoudai}?m=tixian"><span class="iconfont icon-back"></span></a>
    <div class="title">申请提现</div>     
 
  </div>
  
  <form method="post" action="{$appkoudai}?m=tixian&a=save">
   <div class="row center">(提现金额不得少于100元，您目前可提现金额为{$koudai.balance}</div>
  <div class="input-row">
  	<input name="money" type="text" id="money" value="100" >
    <label>提现金额</label>
  </div>
 <div class="input-row">
 	<input type="text" name="yhk_haoma" value="{$last.yhk_haoma}">
    <label>银行卡号码</label>
 </div>
 
 <div class="input-row">
 	<input type="text" name="yhk_huming" value="{$last.yhk_huming}">
    <label>银行卡户名</label>
 </div>
 
 <div class="input-row">
 	<input type="text" name="yhk_name" value="{$last.yhk_name}">
    <label>银行名称</label>
 </div>
 
 <div class="input-row">
 	<input type="text" name="yhk_address" value="{$last.yhk_address}">
    <label>开户地址</label>
 </div>				
  
  <div class="input-row">
 	<input type="text" name="telephone" value="{$last.telephone}">
    <label>联系电话</label>
 </div>	
  
  <div class="textarea-row">
  	<label>备注</label>
    <textarea name="info" type="text" id="info" value="100"  ></textarea>
    
  </div>
  <div class="input-row"><button class="btn btn-row">确定申请</button></div>
 
</form>
</body>
</html>
